Modification of the gum elastic bougie.

ants alone and the frontal electromyogram disappeared and returned in step with the decline in BIS values. They hypothesized that the algorithm calculating the BIS was being unduly influenced by EMG signal loss. Correspondents (2– 4) pointed out the following: 1) neuromuscular blockade reduces proprioceptive input, well known to reduce electroencephalogram (EEG) activity; 2) the 10% of the population with a low-voltage EEG can show awake BIS numbers as low as 40; and 3) it may have been unethical for knowledgeable doctors to volunteer for their own study, because it would be unpleasant. Might cosmetic paralysis of the frontalis muscle with botulinum toxin affect the BIS, inappropriately reassuring an anesthesiologist that the patient was asleep? Perhaps the time has come to include cosmetic questions in the anesthetic questionnaire and to investigate a potential problem directly.